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Seminar

on

VERTICAL
MAXILLO-MANDIBULAR
RELATIONS

PRESENTED BY

CAPT ARUN KUMAR KV


RESIDENT OFFICER
DEPT OF PROSTHODONTICS
ADC (R & R)

CONTENTS

1. Introduction
2. Review of Literature
3. Importance of Recording Vertical Jaw Relation
4. Methods of Recording Vertical Jaw Relation
5. Evaluation of Vertical Dimensions
6. Conclusion

INTRODUCTION
An accurate three-dimensional record of centric jaw relation is considered essential
to the development of a satisfactory complete denture occlusion regardless of the particular
method or devices used. Recording of jaw relations in the treatment of edentulous patients
aims at facilitating the adaptation of the complete denture to the masticatory system to give
them an optimal and comfortable function. To achieve this goal, the recording must include
an approximate vertical dimension of occlusion, stable occlusal contacts in harmony with
the existing TMJ and masticatory muscle functions and the relationship between the
prosthesis and the oral and facial tissues and musculature.
Jaw relations are important for two reasons:
1. The functions served by the artificial teeth depend on the jaw relations.
2. Acceptable jaw relations aid in the preservation of the tissue health.
The registration of vertical dimension has remained a matter of clinical judgment an
art rather than a science. It is linked with horizontal relations insofar as the ultimate
success or failure of the dentures depends on the proper registration of both. The dentist
cannot change one without another. The horizontal relationship known as centric relation is
valid only at specific vertical dimension and if this is changed, a new record must be made.
Jordan has defined vertical dimension as "the length of the profile of the face as it
may be affected by raising or lowering the mandible."
The second edition of the Glossary of Prosthodontic Terms' defines it as "a vertical
measurement of the face between two arbitrarily selected points which are conveniently
located, one above and one below the mouth, usually in the midline." Both of these
definitions refer to a general vertical maxillomandibular relationship.
Thomson and Brodie (1942) stated, The proportions of face as far as vertical height
is concerned, are constant through out life.
According to GPT 2005 Vertical jaw relation is defined as The length of the face as
determined by the amount of separations of the jaws
This record provides the optimal separation between the maxilla & the Mandible.
Which depends on the TMJ & the tone of muscles of mastication, if altered there will be
severe discomfort.
The vertical relation can be described as an area rather than a point. The usual
description of the so called free way space itself suggests the area nature of this
dimension. Many methods have been proposed for the determination of the correct vertical
relation of mandible to the maxilla. Some of them have been offered as scientific but as
yet none is accurate. Others have been as helpful aids to good clinical judgment.
Vertical jaw relation can be recorded in two positions.
Vertical dimension at rest position.
Vertical dimension at occlusion.

REVIEW OF LITERATURE
Recognition of rest position of mandible is no a new concept as early as 1771,
John Hunters writing revealed the presence of physiological rest position of mandible as
in all the joints of the body, when the motion is carried to its greatest extent in any
direction, the muscles, ligaments are strained and the person is made uneasy. The state,
therefore, into which every joint naturally falls, especially when we are asleep, is nearly in
the middle between the extremes of motion by which all the muscles and ligaments are
equally relaxed. Hence, it is that commonly and naturally, the teeth of the two jaws are not
in contact; nor are the condyles of the lower jaw so far back in the cavities as they can go.
Human anatomists in the early 1900s believed in the theory that at birth the gum
pads of the jaws were in contact; and with the eruption of the teeth and growth of the
alveolar process, the jaws are forced apart thus increasing the vertical dimension of
occlusion. They also believed the same process occurred in reverse in old edentulous
patients.
Wallisch (1906) was the first to define the physiological rest position of the mandible.
He described it as the position of mandible where in all the muscle action is eliminated and
the mandible is passively suspended. He also said that, in this position the teeth do not
contact.
In late 1920s Sicher & Tandler, restated the role of musculature in controlling the posture
of the mandible. They stated the rest position of the articulation, the 'Middle Position', is that in which the
mandible is at a slight distance from the maxilla. In this position the mandible is kept against gravity by the
forces of the closing muscle.

Niswonger (1934 & 1938) was the 1st investigator to study extensively the rest
position of the mandible by recording measurements on patients. He referred to the rest
position as the neutral position of the mandible since the opening and closing muscles are
in a state of equilibrium.
Ralph H Boss (1940) showed the recording of the intermaxillary relations by using
biting power.
Schlosser (1941) conducted a series of phonetic experiments indicating that the
movements of the mandible during speech were subjected to habitual fixation. He also
found a space of 1-3 mm between the upper and lower incisors with the lips in contact
when natural teeth were present.
Gillis RR (1941) Supported the Niswongers study on rest position he defined the rest
position of mandible as that position from which all mandibular movements begin to
which they return
Thomson RR and Brodie AG (1942) studied the factors attributing to the position of
mandible. Thomson believed that the rest position is determined by a balance of tension in
the musculature which suspends the mandible and that the rest position is not affected by
the presence or absence of teeth.

He said that basic maxilla - mandibular relations is established before the eruption of teeth
and maintained even after the loss of all teeth
Thomson RR (1946) performed cephalometric analysis of the rest position in
edentulous and semi edentulous adults. These studies confirmed his opinion that rest
position was stable and could not be permanently altered by prosthetic restoration.
Leof M (1950) pointed out that it is the muscle tone rather than the muscle length
which controls the rest position and that the muscle tone can and does vary. He further
stressed that the interocclusal clearance must never be eliminated
James E Pyott and Aaron Schaeffer (1952) presented a technique of simultaneously
recording of Centric occlusion and vertical dimension scientifically. The apparatus
employed for this technique was the cepahlometer.
Meyer M Silverman (1952-1953) presented a physiologic phonetic method of
measuring the vertical dimensions of the closest speaking space. This space is measured
before the loss of natural teeth to give us the patients natural vertical dimension which can
be recorded and used at a later date.
Sicher H (1954) agreed with Thomson and Brodie that the mandibular position is
completely dependent on the tonicity of the musculature. The rest position showed
constancy under normal conditions of health and disturbed in cases of nervous tension
disease or overwork.
Meyer M Silverman (1955) outlined the significance of the pre extraction records to
avoid premature ageing of the denture patient. He points out that the basic portion of the
patients natural dentition should be duplicated. This prevents the failures of complete
dentures and avoids the unnecessary aged appearance of the patient.
Douglas Allen Atwood (1956) performed a cephalometric study to study the variability
of the clinical rest position following the removal of occlusal contact. His study suggests
that resting vertical dimension in edentulous patients shows a range of variations which
varies from one patient to another and within the same patient from time to time.
Duncan and Williams (1960) performed a study on the rest position as a guide in
prosthetic treatment. They found a reduction in the pre-extraction height of face with the
teeth in occlusion as related to the corresponding the face after prosthetic Treatment. A
general reduction in the height with the mandible in rest position was also observed after
removal of occlusal contacts. The instability found in rest position let the investigator to
conclude that rest position is a poor guide for establishing pre extraction occlusal vertical
dimension
Robert Lytle (1964) presented a technique that aids in determining the tentative
vertical relation in occlusion for an edentulous patient. The central bearing device is used
to permit the patient to experience different vertical relations for comparison.
Herbert Swerdlow (1965) provided a review of the previous studies conducted on the
subject of vertical dimension. He categorized the literature under two broad headings.
Constancy concept of face height
Variability of rest position
Douglas and Maritato (1965) described the open rest method of establishing vertical
dimension of occlusion. Open rest position is an unstrained mouth breathing position. The

authors claimed that this method is more accurate than the previous ones using rest
position, tactile sense & swallowing methods to determine the vertical dimension of
occlusion.
Coulouriotes (1885) in his article on freeway space stated that not one scientific and
absolute method is available where by an exact inter occlusal distance can be determined
and measured.
DR Farhat Fayz, DR Ahmad Eshami (1988) put forward a literature review of the
various methods for determination of occlusal vertical dimension. They concluded that
there were no significant advantages of one technique over another, other than those of cost
time and equipment requirements.
Mayer M Silvermann (2001) outlined a very practical method of measuring vertical
dimension. It is a physiologic and phonetic method which measures vertical dimension by
means of the closest speaking space.

Physiological rest position


Definition: - The mandibular position assumed when the head is in upright position & the
involved muscles, particularly the elevator & depressors groups, are in equilibrium in tonic
contraction, & the condyles in neutral, unstrained position GPT
This position is established by the muscles (opening and closing) & gravity.
It is a postural relationship of the mandible to the maxilla & the teeth do not
determine the level of this relationship. Since the gravity exerts a force on the mandible,
this force is added to the force from muscles applied to the mandible, and therefore the
position of the head is important when observations of the vertical relation of rest are
recorded. Specifically, the head must be held in an upright position by the patient and not
be supported by a head rest when these observations are made.

Vertical Dimension at Rest


Definition: - It is the length of the face when the mandible is in rest position-GPT
It is essential to record the vertical dimension at rest as it acts as a reference point during
recording the vertical dimension at occlusion.
VD at Rest = VD at Occlusion + Freeway space
The VD at rest should be recorded at the physiological rest position of the mandible.
When functional movements are performed, the mandible comes to physiological rest
position.

Vertical dimension at occlusion:


Definition: - It is the distance measured between the two points when the occluding
members are in contact.
It is the length of the face when the teeth (occlusal rims) are in contact and mandible in the
mandible is in centric relation.

Free way space


It is the difference between the occlusal vertical relation & the vertical relation at rest
position.
It ranges from 2-4 mm in vertical direction at the position of the 1st premolar.

Importance of vertical Jaw relation


Vertical jaw relation is the most critical record because errors in this record produce
the 1st signs of discomfort.

Increased Vertical Dimension


1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Clicking of the dentures during speech.


Soreness of the tissues of the basal seat
Rapid destruction of the residual alveolar ridges
Pain in the muscles of oro-facial complex due to overstretching.
Increased in lower face height
Anterior positioning of the condyles.
Pain in the TMJ region.
Poor esthetics.
Difficulty in swallowing & speech.
Cheek biting

Discomfort
The patient has acquired, over a period of many years, a cortical pattern which
controls, automatically and unconsciously, certain muscular movements, amongst them
being those of the tongue and mandible when eating and talking. An example, which can
be readily appreciated, of this unconscious control will be found in the act of running up a
flight of stairs. The steps being all the same distance apart, one's weight is taken evenly
and smoothly on each successive stair without any conscious thought, but if, without one's
previous knowledge, one tread is at a different height from the others, a very nasty jar will
result. In an exactly similar way, the pressure is smoothly and gradually applied to the food
between the teeth when eating, but if the height of a tooth is altered, for example by a lead
shot resting on the occlusal surface, a very unpleasant jar will draw attention to what is
normally a purely automatic movement. By altering the vertical height the environment in
which these unconscious movements take place has been altered and, until a new cortical
pattern has been established, considerable discomfort will be caused.

Trauma
The jarring effect of the teeth coming into contact sooner than expected may cause only
discomfort, but in most cases it will also cause pain owing to the bruising of the mucous
membrane by these sudden and frequent blows. Particularly is this so under the lower
denture whose area to resist pressure is so much less than the upper. Easing the fitting
surface over sore areas does not cure this trouble; it only destroys the fit in one part and
increases the pressure in another.
Loss of Freeway Space
Loss of the normal space between the occlusal surfaces of the teeth, when the
mandible is in the rest position, may have several effects, one of which is nearly always
annoyance from the inability to find a comfortable resting position. Other effects may be
trauma caused by the constant pressure on the mucous membrane and muscular fatigue of
anyone, or any group of the muscles of mastication.

Clicking Teeth

The tongue has become accustomed to the presence of teeth in certain fixed
positions, and during speech helps to produce sounds without the teeth coming into
contact. When, however, these teeth are raised, due to too great a vertical height, opposing
cusps frequently meet each other, producing an embarrassing clicking or clattering sound.
This same effect is also often produced during eating, but is not as obvious as it is muffled
by the food.

Appearance

The result of over-opening must be an elongation of the face, but if it is only slight
it will usually pass unnoticed. What will, however, generally be obvious, is that at rest the
lips are parted, and that closing them together will produce an expression of strain.

Reduced Vertical Dimension


1.
2.
3.
4.
5.
6.
7.
8.

Comparatively lesser trauma to the denture bearing area.


Decreased lower facial height.
The lips loose their support. Thinning of vermilion borders of the lip.
The corners of mouth are turned down because the orbicularis & its attaching
muscles are pushed too close to their origin.
Angular chelitis due to folding of the corner of the mouth.
Pain, clicking, discomfort of the TMJ accompanied with headache &
neuralgia.
Loss of muscle tone.
The reduced vertical relation --loss of the cubicle space of the oral cavity-reduced interarch distance --which push the tongue towards the throat--adjacent tissues will be displaced & encroached upon results in occlusion of
the Eustachian tubes, which would interfere with the functioning of the ear.
This may cause ear discomfort.

Inefficiency
This is due to the fact that the pressure which it is possible to exert with the teeth in
contact decreases considerably with over-closure because the muscles of mastication are
acting from attachments which have been brought closer together.

Cheek Biting
In some cases where there is a loss of muscular tone, as well as a reduced vertical
height, the flabby cheeks tend to become trapped between the teeth and bitten during
mastication. When the over-closure has been deliberate, it is possible to avoid this cheek
biting by setting the upper posterior teeth more buccally than normal, thus producing a
greater overjet. Also by plumping the buccal flange of the denture the check may be given
added support.

Appearance
The general effect of over-closure on facial appearance is of increased age: there
is closer approximation of nose to chin, the soft tissues sag and fall in, and the
lines on the face are deepened. The greater the degree of over-closure, the more
exaggerated are these effects.

Soreness at the corner of the mouth (Angular Chelitis)


Over closure of the vertical height sometimes results in a falling in of the
corners of the mouth beyond the vermilion border and the deep fold thus formed
becomes bathed in saliva; this area may become infected and sore and is then
difficult to cure whilst it remains moist. Opening the vertical height restores the
corners of the mouth to their normal position, sometimes producing a marked
improvement or cure. A deep natural fold cannot be eliminated by this means
and in no case must the increased vertical height exceed the free way space. -

Pain in the Temporomandibular Joint


In cases of gross over-closure of the jaws, pain in the temporomandibular joint may
occur, probably due to strain of the Joint and associated ligaments, which may be relieved
by restoration of the correct vertical dimension.

Costen's syndrome
Costen's syndrome is stated to be the result of prolonged over-closure, though his
explanation of how these symptoms are produced is now doubted. It consists of:
(a) Mild catarrhal deafness and dizzy spells which-are relieved by inflation of the
eustachian tubes.
(b) Tinnitus, or at times a snapping noise in the joint which is experienced while chewing.
Painful limited or excessive movements of the affected joint.
(c) Tenderness to palpation over the temporo-mandibular joint or dull pains.
(d) Various neuralgic symptoms such as burning or prickling sensation of the tongue, throat
and side of the nose. Various forms of atypical head pain particularly that referred to the
temporal region or the base of the skull.
(e) Dryness of the mouth due to disturbed salivary gland [unction.
Therefore while considering all the methods of recording the rest position, one must
remember that both excessive and reduced vertical relations at occlusion are both
potentially damaging either to that: supporting structures or to the TMJ

METHODS OF DETERMINING VERTICAL JAW


RELATIONS
Establishing correct vertical jaw relations is one of the most important steps in making
complete dentures. Although advances in techniques and materials are being made, still no
accurate method of establishing vertical jaw relations in edentulous patients is available.
Clinical judgment still plays a major role in the assessment of this component.
There are several methods which are given in literature to determine the vertical jaw relation
They can be broadly classified into:
I) Mechanical methods

II) Physiological methods

I) Mechanical methods - include:

I) Ridge Relations
a) Distance of incisive papilla from mandibular
incisors
b) Parallelism of the
ridges.
2) Measurement of former dentures.
3) Pre-extraction records
a) Profile radiographs
b) Casts of teeth in occlusion
c) Facial measurements
d) Profile photographs
4) Cephalometry
II) Physiological Methods:
1. Physiological rest position
2. Esthetics as guide
3. Swallowing threshold
4. Tactile sense method
5. Power Point / measurement of closing force
6. Facial measurements
7. Phonetics
8. Facial expressions
9. Open rest method
I) MECHANICAL METHODS:
1) RIDGE RELATIONS:

a) Distance of the incisive papilla from the incisal edge of the mandibular anterior
teeth Incisive papilla is a stable landmark and is changed very little by resorption
of the residual alveolar ridge. The distance between incisive papilla and incisal
edge of mandibular anterior teeth on diagnostic cast averages approximately 4 mm

in the natural normal dentition. The incisal edge of the maxillary central incisors is
an average of 6mm below the incisal papilla Therefore the average vertical overlap
of the opposing central incisors is about 2 mm.
b) Parallelism of maxillary and mandibular ridges
Crest of the lower residual alveolar ridge will be approximately parallel with
crest of upper residual alveolar ridge when jaws are at position of vertical dimension
of occlusion. This relationship provides ideal situation for stability of denture.
Therefore, parallelism of maxillary and mandibular ridges plus 5 degree opening in
the posterior region as suggested by Sears often gives a clue to the correct amount of
jaw separation.
However, in most people the teeth are lost at different times and so by the
time the patients are edentulous, the residual ridges are no longer parallel
2) MEASUREMENT OF FORMER DENTURES:
Dentures that the patient has been wearing can be measured, and the
measurements obtained co-related with observations of the patients face. This helps
to determine the amount of change in vertical relation at occlusion that is required.
These measurements are made between the border of the maxillary and
mandibular dentures by means of a Boley Gauge. Then if observations of the
patients face indicate that this distance is too short, a change can be made in the
denture.

3) PRE-EXTRACTION RECORDS:
Following pre-extraction records can be utilized for determining vertical relations.
A) Profile Radiographs
Profile radiographs of the face or of position of condyles may be used, but the
problem of establishment of vertical relation of rest or enlargement of image can cause
inaccuracies. The inaccuracies that exist in either techniques or the methods of making
measurements can make these methods unreliable.
B) Casts of teeth in occlusion:
A method of recording the vertical overlap relation as well as the size and shape
of the teeth is through the use of diagnostic cast mounted on an articulator. The casts
serve as an indication of the amount of space required between the ridges for teeth of
this size. The distance between the residual ridges of the articulated casts can be
compared with that of casts mounted prior to the extraction of teeth.
C) Facial Measurements:

Devices have been made to record the relation of the head to the central incisors
vertically and antero-posteriorly by placement of a face bow with auditory meatus
plugs in position with spectacle suspension. Another method used is to record the
distance from the chin to the base of the nose by means of a pair of dividers before the
teeth are extracted. Still another method is to use a pair of calipers to find the distance
from the undersurface of the chin to the base of the nose. Tattoo points can be placed,
one on the upper half of the face and other on the lower half
IVY in 1887 mentioned the use of facial measurements to determine the vertical dimension
of edentulous patient.
. Good Friend in 1933 suggested that the distance from the pupil of the eye to the
junction of the lips equaled that from the subnasion to the gnathion. However, Willis in
1935 has been given credit for popularizing these measurements.
McGee in 1947 co-related the known vertical dimension of occlusion with three
facial measurements which he claimed remain constant throughout life. Then three
measurements are:
(l) The distance from the center of the pupil of the eye to a line projected laterally
from the median line of the lips.
(2) The distance from the glabella to the subnasion.
(3) The distance between the angles of the mouth.
McGee state that two of these measurements will be invariably equal and
occasionally all three will be equal to one another. He claimed that in 95% of his
subjects with natural teeth, two or three of these measurements correspond to the
vertical dimension of occlusion.
Hurst in 1962 adopted a method based upon the length of the upper lip and the
amount of the central incisor that is exposed when the lips are parted in repose.
Measurements were made on selected subjects with natural teeth. The subjects were
divided into 5 types whose upper lip ranged from extra short to extra long. He
measured the inter-occlusal distances and found that this space ranged from 1 mm for
that group with the longest upper lips. This information enabled him to develop a
table which can be used for determining the occlusal vertical dimension for all
edentulous patients.
Chow, Darsey, Young and Glarus in 1994 conducted a study to determine the
vertical dimension of occlusion by a craniometric method. The chin, nose distance was
measured and co-related with the right and left ear-eye distance and it was concluded
that1. Left ear-eye distance can be used to predict chin nose distance
with reasonable accuracy. However the algorithm for making
this prediction is not the same for combinations of sex and
ethnic origin.
2. The diagnostic measurement device can be used as all
additional aid in existing physiologic measurements so that
absence of adequate inter-ridge distance can be predicted.

ANA TOMIC LANDMARKS:


Devices have been made to record the relation of the head to the central incisors
vertically and anteroposteriorly by placement of a face bow with auditory meatus plugs in
position with spectacle suspension. Another method is to record the distance from the
chin (lower border of mandible) to the base of the nose (anterior nasal spine) with either a
pair of divides or calipers. This measurement when equals the distance from the pupils to
the rima oris, measured by a Willis guide, the jaws are considered at rest.
PROFILE PHOTOGRAPH
These are enlarged to lift size. Measurement of anatomic landmarks on
the photographs is compared with measurements using the same
anatomic landmarks on the face. These measurements can be compared
when the records are made and again when artificial teeth are tried in. the
photographs should be made with the teeth in maximum occlusion, as the
position can be maintained accurately for photographic procedures.
CEPHALOMETRY
James E. Pyott calculated rest vertical dimension in edentulous patients by making
cephalometric radiographs at the physiologic rest position produced by swallowing and by
an arbitrary centric occlusion. He then measured the distance between the function of the
nasal and frontal bones and the most protrusive point on the symphysis of the mandible.
The record bases were adjusted until there was approximately 3 mm of jaw separation
between the rest position and the vertical dimension of occlusion.
One of the most extensively documented studies and the rest position was
performed by Douglas Allen Atwood. He performed a longitudinal roentogenographic
analysis of the face heights before and after extraction on 42 subjects. Atwood found the
cephalometric method to be most accurate for determining rest position. He also reported
a variation in measurements between settings and during the same setting, between
readings with and without denture.

Physiological Rest Position


Perhaps the most widely used guide for determination of the occlusal vertical
dimension in edentulous individuals is the physiologic rest position of the mandible.
Niswonger defined this posture as a neutral position wherein the mandible is involuntarily
suspended by the opening and closing muscles. Conflicting reports have been made on the
stability of this position, but much of the disparity can be attributed to differences in
investigative technique and in interpretation of the term "stability." From a clinical
standpoint, measurements of rest position without dentures in the mouth are usually within
1 mm. of the average when taken at a single sitting, or at sittings days or weeks apart; but
greater variability about the average can be expected when measurements are taken at
sittings months or years apart.

The range of variation appears to differ between individuals and over a period of time
in the same individual. However, mandibular rest position can be useful as a clinical
reference posture if care is exercised to minimize physical, psychological, and
environmental influences, and if enough controlled registrations are made to validate an
average measurement. For example, the determination of rest position is most difficult if
the patient is in pain, under undue emotional stress, overly fatigued, under anesthesia or
heavy sedation, or if he has an elevated body temperature. Furthermore, if dentures are
being worn during the course of treatment, the existing vertical dimension of occlusion
should be carefully evaluated because reflex patterns associated with habitual posture may
very well influence the recording of an acceptable rest position. A 12 to 24 hour period
without dentures in place is recommended as a minimum corrective measure.

Many patients, especially those who have worn one set of dentures for many years, require
considerably more in the way of preparatory therapy. Treatment prior to actual denture
construction should include conditioning of the musculature as well as preparation of the
denture bearing soft tissues. It is usually started prior to impression making and is
continued through all clinical procedures up to the insertion of the new dentures. It may
include any or all of the following: functional exercises, intraoral digital massage, resilient
denture liners, a soft diet, and a rest period without dentures.
An acceptable clinical technique must also provide for the effect of posture. That is, the
head, neck, and torso should be in a state of "postural balance" while the measurements
are being made. This can be reasonably effected if the patient is seated in an erect but
comfortable position with the head (unsupported by a headrest) oriented so the Frankfort
plane is parallel to the floor. It can also be accomplished by having the patient stand in a
natural posture, with the weight equally distributed between both feet and the head
oriented as just described. Two reference marks are placed on the patient's face in the
midline, one on the tip of the nose, the other on the chin. The patient is asked to
pronounce several words ending in m, such as "museum" and "minimum," wet the lips,
swallow, and relax. The distance between the reference marks is then measured. This
process is repeated several times. If 4 to 6 successive measurements are within 1 mm,
the distance is recorded as that of rest position. However, if a greater variation occurs, 10
to 15 measurements should be made and the average accepted as the proper distance.

To record the occlusal vertical dimension, both previously prepared occlusion rims
are replaced in the patient's mouth and the mandibular rim is adjusted as necessary to meet
the maxillary rim evenly when the distance between the reference marks on the face is
reduced by 3 to 6 mm. This distance has come to be considered as providing an acceptable
average interocclusal distance of 2 to 5 mm. Naturally; some patients will not fit the
average category. Therefore, an effort must be made to determine the particular needs of
each patient to be treated. Unfortunately there is no precise formula for calculating this
distance. Instead, some suggestions are again offered for guidance. It has been
recommended that more than the average interocclusal distance should be provided for
elderly persons. The same consideration should generally be given patients who have
suffered extreme losses of alveolar bone. Orthognathic persons also usually require more
than average interocclusal clearance. However, the patient's general facial appearance may
be adversely affected, and the tongue may be restricted if the occlusal vertical dimension is
decreased too severely.
On the other hand, if insufficient interocclusal clearance is allowed, many clinicians have
indicated that an accelerated change in occlusal vertical dimension occurs, which mayor
may not be accompanied by evidence of soft tissue abuse. The mere fact that "space" is
evident between the occlusal surfaces of opposing teeth when a patient wearing complete
dentures is asked to "rest" the jaw is not indicative of an adequate interocclusal
relationship. A recent long-term study6 has shown that the greatest changes in the vertical
dimension of occlusion occur when the initial occlusal vertical dimension is equal to or
greater than the resting face height without dentures in the mouth. If the vertical dimension
of rest position without dentures is greater than the occlusal contacting dimension, the
prognosis, as it pertains to vertical jaw relationship, is good. In fact, if the average resting
face height without dentures exceeds the occlusal vertical dimension by 4 to 5 mm. at the
time the dentures are inserted, the vertical dimension of occlusion should theoretically
remain unchanged on the average for approximately six years. These observations should
at least challenge each clinician to compare the vertical dimension he has tentatively
selected for a patient, regardless of the method he has used in his selection, with the
patient's rest position without dentures before he makes his final determination.

Tactile sense method (Neuromuscular Perception)


In tactile sense method patient is asked if the occlusion rims, and/or arranged teeth,
feel as though they "hit" too soon, too late, or about right. Obviously, this is a very
subjective approach, but some people do seem to have the proprioceptive capability this
procedure requires. In fact, Lytle has explored the phenomena of neuromuscular
perception rather extensively and has outlined a clinical procedure which may well be very
effective in a large percentage of cases.
Briefly, his technique involves the use of a central bearing apparatus mounted on
stable, well adapted record bases. Regardless of the method to be used, the success of the
recording of an accurate jaw relation is largely dependent upon the accuracy of the record
bases. They must fit the mouth and the cast equally well. An adjustable central bearing pin
is mounted on the lower base with modeling composition. A bearing plate is similarly
mounted in the palatal area of the upper base. The pin, which is longer than those normally
found in these assemblies, is initially elevated well beyond the level of an acceptable
vertical dimension of occlusion. The patient is asked to tap twice in rapid succession with
the mandible in its most retruded position (some patients may require guiding assistance to
accomplish this). This process is continued as the pin is lowered 1/2 mm. at a time. The
patient is asked to inform the operator when he feels that he has closed "too far." The
exposed threads on the pin are counted and recorded.
The procedure is then repeated, starting at an obviously decreased vertical dimension,
and the pin is adjusted to increase the vertical level of contact 1/2 mm. at a time. This time
the patient is asked to signal when he feels that he has opened "too far." The threads are
again counted, and compared with the "closed" count. The difference is split and the
tapping process repeated. The patient is given only two choices during each trial hereafter.
He must select the level which "feels better."
In the final analysis, through trial and re-trial, the patient's perception or tactile sense
determines the occlusal vertical jaw relation.
To date Lytle's findings indicate this procedure to be both effective and repeatable, but
he does caution the clinician to consider this a tentative relationship which may require
modification if other accepted tests fail to validate the dimension so selected.

Esthetic As Guide
The vertical relation of the mandible to the maxillae also affects esthetics. A study
of the skin of the lips compared with the skin over other parts of the face can be used as a
guide. Normally the tone of the facial skin should be the same throughout. However, it
must be realized that the relative anteroposterior positions of the teeth are at least equally
as involved in the vertical relations of the jaws as in the restoration of skin tone. The
contour of the lips depends on their intrinsic structure and the support behind them.
Therefore the dentist must initially contour the labial surfaces of the occlusion rims so they
closely simulate the anteroposterior tooth positions and the contour of the base of the
denture. This contoured surface must replace or restore the tissue support provided by the
natural structures. If the lips are not properly supported anteriorly, they will be more nearly
vertical than when supported by the natural tissues. In such a situation, the tendency is to
increase the vertical dimension of occlusion to provide support for the lips, and this can
lead to excessive lower face height. The esthetic guide to an appropriate vertical
maxillomandibular relation is, first, to select teeth that are the same size as the natural teeth
and, second, to estimate the amount of tissue lost from the alveolar ridges. However, recent
evidence suggests that this method of estimating the appropriate vertical dimension is a
relatively unreliable one. In a study of young dentate individuals (where the issue of lip
support is eliminated), dentists gave relatively poor estimates of the effects of changes in
vertical dimension from facial photos when the vertical dimension was artificially opened
between 2 and 6 mm. This method should therefore be used with caution or in combination
with other methods.

Swallowing Threshold
Gillis and Shanahan are among those who have suggested use of the act of
swallowing as a guide to an acceptable occlusal vertical dimension. They conclude that the
act of swallowing is "patterned," and that the pattern remains relatively consistent
throughout life. Consideration must naturally be given to the effects of degenerative
changes which occur as a part of the aging process. However, they maintain that if care is
exercised in evaluating the swallowing level at intervals, the resulting vertical dimension
of occlusion will incorporate an adequate interocclusal distance. The recommended
techniques vary slightly, but, in general, accurately fitted record bases and carefully
contoured occlusion rims are again stressed as preliminary requirements.
The anterior length of the maxillary occlusion rim is established to simulate the length
of the anterior teeth. The occlusal plane is made parallel to the ala tragus line, and the
lingual and facial contour must allow for tongue space, and provide support for the lips
and cheeks. The lower record base and occlusion rim must be similarly fitted and
contoured. A preliminary registration of the vertical dimension of occlusion is made using
any of a number of methods (e.g., neuromuscular perception, physiologic rest position,
phonetics, facial expression, etc.). The mandibular rim is then reduced by 2 to 5 mm, and
three small cones of very soft wax are placed on top of the lowered rim in the midline and
in each second bicuspid or first molar area. The trial bases are then positioned in the
patient's mouth and he is asked to swallow saliva several times. The mandibular rim is
removed from the mouth and chilled. The vertical dimension of occlusion so determined
should then be compared with the results of other methods.
In a clinical study to evaluate the swallowing method, Ward and Osterholtz concluded
that "time, judgment, and control of the patient" were essential requirements. Furthermore,
they recommended the removal of previous dentures for a period of time before a record is
attempted in order to invalidate acquired neuromuscular reflex patterns.

Measurement of Closing Force To Establish Vertical Dimension/ Power Point


This theory is based on the premise that the maximum closing force can be exerted
when the mandible is at the vertical dimension of rest position as stated by Ralph H Boos
in 1940.
Procedure:

A force bimeter (Boos Bimeter) is attached to an accurately made


record base. Attach a metal plate in the vault of an accurately adapted base to provide a
central bearing point. Adjust the vertical distance by turning the cap. The gauge indicates
the pounds of pressure generated during closure at different degrees of Jaw separation.
When the maximum power point is determined, lock the set. Make plaster registration and
transfer the cast to the articulator.
Boos stated that as the functions of all muscles are coordinated under certain
conditions, considerable power can be generated. This power is limited by the individual
circumstances and the ability of the occlusion or ridge to withstand pressure. The
important point of muscle function is that there is a critical point in the distance from the
origin to the insertion at which the muscle can exert the greatest force in contraction.
When the distance from origin to insertion is shortened:

Muscle becomes less efficient and tends to lose tone. If this reduced, distance is
maintained over a long time, the muscles do not regain their maximum power.
When the muscle is stretched beyond the critical point:

Again efficiency of the muscle is reduced; the muscles tend to regain their normal
length unless the resistance is greater than the strength of the muscle

The length of the muscles of mastication which provide the biting force is changed
with the opening and closing of the mandible. The physiologic factors in muscle structure
provide a basis of study of the efficiency of intermaxillary positions. With this thought, a
'gnathodynamometre' was developed which could record upto 100 pounds pressure. An
examination involved the registration of maximum biting force in various vertical positions
in edentulous cases. In this way, the position of maximum efficiency can be determined on
the individual patient. The registration is based on an examination of all the factors in
denture construction. These factors are:
1. Muscle strength
2. Tissue tolerance
3. Stress bearing areas
4. Condition of the patient
Boos also considered the centric relation, or the lateral and the anteroposterior
position of the mandible in relation to the maxilla. The horizontal position was recorded
by the central bearing point marking on the central bearing plate. This was verified by an
extra oral registration. This point of the intermaxillary relation, which included the
horizontal and the vertical position, was termed the 'power point' or that relation of the
mandible to the maxillae at which the greatest power can be recorded.
Boos finally converged on to two fundamentals in the intermaxillary relations,
which could be applied to practical denture construction..

First, the constant point of vertical maximum


power.

Second, the relation of horizontal position.

These combined provide the 'power point'.


Smith in 1958 stated that the Boos Bimeter was the first approach for determining
vertical dimension of rest position. However, the bimeter was condemned because pain
and apprehension influence the closing power of the patient.
Tueller, YM 1969, used an electronic method to determine the vertical separation of the
jaws at which the subjects could exert the maximum closing force. This device consisted
of a steel spring and strain gauze mounted in the palate of a resin base plate. The lower
base plate carried a central bearing point. The strain gauze was linked to an amplifier and
pen recorder. The vertical dimension, which produced the greatest deflection, was called
the Power Point, which was considered to represent the rest position of the mandible.
6) Facial Measurement :

o Patient is instructed to sit/stand comfortably upright, eyes looking straight


ahead at some object which is on the same level.
o Maxillary occlusal rim and record base is instructed.
o Two points of reference are marked with an indelible marker or a triangle
of adhesive tape: one at the end of patients nose and another on the point
of the chin.
The patient is instructed to wipe his lips with the tongue, to swallow and to drop
the shoulder.
When the mandible drops to the rest position, measure between the points of
reference. A millimeter ruler is convenient, it will not alarm the patient as it is being
positioned against the face.
Repeat this procedure until the measurements are consistent. Such measurements
are helpful but not absolute. The vertical dimension of occlusion can be adjusted to
approximately 2-4 mm less than the recorded vertical dimension at rest.
7) PHONETICS

-THF. "F" or "Y" and ''S'' Speaking Anterior Tooth Relation


Incisive guidance is established by arranging the anterior teeth in the occlusion
rims before recording the vertical dimension of occlusion. This method was developed
by Pound and Murrell.
Position of maxillary anterior teeth is determined by the position of the maxillae
when the patient says words beginning with "f" or "V".
Position of the mandibular anterior teeth is determined by the position of the
mandible when the patient says words beginning with S.
Steps:
Make stable record bases - maxillary and mandibular.
Contour the maxillary occlusion rim using hard baseplate wax. Keep the
labiopalatal and buccopalatal width the same as that of the anterior and posterior

teeth.
Apply hard baseplate wax to a height of 2 to 4 mm over the superior surface of
the mandibular record base place a section of beeswax about 2-4 inch high in the
estimated location of the four anterior teeth. This section of basewax is referred to
as "speaking wax".
Place the maxillary record base with the occlusal rim in the patient's mouth.
Adjust the occlusion rim to provide lip support. When the "f' and "V" sounds
are articulated, the incisal edges of the maxillary anterior teeth create a seal on the
moist area of the vermillion border of the lower lip.
Have the patient repeat the word "first"' or "victor" and contour the wax to create
the seal. The seal can be checked by having the patient repeat or read the numbers
"five-' and "fifty-five".
Record the midline on the wax rim and arrange the two artificial central incisors,
one on each side of the midline, with the incisal edges at right angles to the long
axis of the face at the determined incisal length for lip seal. The incisal edges
form a seal by contacting the lower lip.
Remove the record base from the mouth and arrange the artificial lateral incisors
and cupids.
Place the incisal edges of the artificial lateral incisors and cuspids at the same
level as the central incisors. Keep the labial surfaces in harmony with the
contoured occlusion rim. This may or may not follow the form of the arch to give
lip support.
Return the maxillary record base to the mouth and make changes necessary for
natural appearance. The incisal edges should follow the curvature of the lower lip.
Seat the mandibular record base with the attached "speaking wax". Have the
patient repeat the number '6' and '65' and adjust to the "S" position.
When the "S" sounds are articulated, the mandible moves forward. The incisal
edges of the anterior teeth do not make contact.
Having the patient pronounce words beginning with f or "S" will bring forth
conscious speech patterns; that are not adequate for determining the position.
Unconscious, more natural speech patterns with the words recurring fairly
quickly can be produced by asking the patient to read a newspaper article or a
poem.
Record the center line on the wax rims to co-incide with the midline of the
maxillary central incisors.
Remove the mandibular record base from the patients mouth and remove the
"speaking wax" from one side of the center line. Replace the wax with the central
and lateral incisors, with the necks of the artificial teeth inclined toward the crest
of the residual ridge. Then remove the remaining wax and arrange the other
artificial central and lateral incisors.
Return the mandibular base to the mouth and refine the four artificial teeth to the
"S" position. This position represents the protrusive phase of the incisal guidance.
Adjust the hard wax rim on the maxillary record base to parallel the "camper's
line'. Place notches in it to aid in repositioning the vertical dimension and central
occlusal records.

Place the soft recording wax on the posterior surfaces of the mandibular base to a
height that exceeds the anticipated vertical dimension of occlusion. Seal it to the
hard wax.
Place the maxillary record base with the attached teeth on the wax rim in the
mouth and assure that it is stable and is retained.
Seat the mandibular record base in the patients mouth. Ask the patient to retrude
his mandible from the "s" position to a comfortable retruded relation and then to
close vertically until a firm posterior contact is encountered.
Remove the record from the patients mouth and check for alignment and
sufficient. Correct any discrepancies and remove excess wax.
Re-insert the record base and repeat step until the incisal edges of the mandibular
anterior teeth contact firmly against the maxillary teeth or the palate. The latter
can occur in some class II related jaws in which the mandible has a retruded
relation to the maxillae. Firm contact at this point does not mean that the teeth
will be in contact when arranged in centric occlusion.
A record made by this technique may incorporate undue pressure. If the patient is
instructed to open and then make light contact without pressure, the anterior teeth
may not contact as they did. To ensure that the record does not incorporate excess
pressure, the patient must be instructed to return to the retruded position again
close into the record with pressure and then to open. , Repeating this procedure
will develop an acceptable record of the jaws in terminal relation at the correct
vertical dimension of occlusion with minimal pressure, except in some of the
extreme class II relation. In most situations this posterior contact represents the
posterior contact of incisal guidance. It also determines the patients original class
of occlusion.
An Alternate technique - is to use baseplate wax made passive by applying,
plaster, softened impression compound, or zinc oxide eugenol paste as the
recording material. The patient is instructed to retrude from the "S" position to the
terminal relation and close until the anterior teeth make contact. Remount
procedures are instituted for selective grinding
Production of the 'Ch', S' and 'J' sounds brings the anterior teeth very close
together. When correctly placed, the lower incisors are moved forward to a
position nearly directly under the upper central incisors and almost touching
them.
1) If the distance is too large one may have established a very small vertical
distance of occlusion.
2) If the anterior teeth touch when these sound are made, the vertical dimension
is probably too great.
3) If the teeth click together during speech, the vertical dimension of occlusion
is probably too great.
Speech is used in several different ways as an aid to establish rest position.
Two of these methods arc as follows:
1) Have the patient repeat the name 'Emma' until he is aware of the contacting of
the lips as the first syllable 'em' is pronounced. When the patient has repeated

this procedure, make him stop all jaw movement when the life touch. At this
time measure the distance between the two points of reference.
2) Engage the patient in a conversation that will divert his attention from
conscious participation in the procedure. A pause in speech, followed by
relaxation as indicated by a drop of the mandible, is indication for another
measurement.

CLOSEST SPEAKING SPACE - By Silverman


The closest speaking space measures vertical dimension when the mandible and
muscles involved are in physiologic function of speech. It is possible by the use or
speaking method (use of sibilant sounds such as S, Sh, ch ) to measure a patients
vertical dimension before the loss of remaining natural teeth and to record this in terms
of millimeters and to reproduce this measurement in full dentures at a later date.
It is physiologic phonetic method based on the movement of the mandible while
the patient speaks. It is based on the science of phonetics used to teach the deaf and hard
of hearing to speak and is newly applied to dentistry in order to measure the distance
between the upper and lower jaws
The patient is seated in an upright position without the use of a head rest. with
the eyes forward, and the occlusal surfaces of the upper posterior teeth parallel to the
floor. Measurement is taken under identical conditions of the posture and vigour of
speech. Head must not tilt forward or backward, and the patient should speak rapidly in a
calm and relaxed manner. A particular observation must be made that the patient does not
consciously control the movement of the mandible, as any variation from normal might
affect the measurements.

Direct the patient to close into centric occlusion, with the upper and lower teeth
together in maximum occlusal contact. Draw the centric occlusion line with a sharp
pencil on a lower anterior tooth at the horizontal level of the incisal edge of the opposing
upper anterior tooth.
Have the patient say "yes", and while the phonetic sound 'S' is being

pronounced, draw the closest speaking line on the lower anterior tooth at the horizontal
level of the upper incisal edge. The distance between the centric occlusal line (lower
line) and the closest speaking line (upper line) is called the closest speaking space. This
closest speaking space is the measurement for vertical dimension.

In some patients the mandible will move forward during the pronunciation ion of sibi1ing
speech sounds. This forward movement will not affect the accuracy of the measurement because the
same movement occurs, and the vertical distance between the lines is always re-measured in the
same manner with both natural and artificial teeth
The closest speaking space may vary in different individuals. There is no such thing as "an
average" in measuring vertical dimension. Measurements must be made with accuracy, as increase in
vertical dimension by only 1 mm also will cause discomfort to the patient.

If there is a variation in the position of the closest speaking line, it is generally due to a
voluntary muscular control of the lower jaw. When the patient speaks or reads rapidly, the function
of the mandible is unconsciously accurate because all conscious control of the mandible is
eliminated.
Whenever lines cannot be drawn on the lower anterior teeth tooth due to space between the
upper and lower teeth and show how the closest speaking space is measured.
The accurate closest speaking space is eventually obtained by measuring at intervals until
the patient is free of sore sports and is relatively comfortable.
It is always advisable to measure the closest speaking space of all full denture patients at
least once a year until is found that there is an end to discomfort and perhaps to alveolar shrinkage
or wear of the artificial teeth.
Experience has shown that the measurements for the 'free way space' and the 'closest
speaking space' of the same patients are generally not the same. The closest speaking space
measures vertical dimension when the mandible and muscles involved are in the active full
function of speech. The measurement with this method is simple and less time consuming.
It is practical because the measurement can be made in the dentist's office itself in very
less time. It is scientific and accurate. This method is the most practical, scientific and
accurate method of measuring vertical dimension.
The closest speaking space which measures the vertical dimension in this phonetic
method must not be confused with the fee-way space of the physiologic method reported
by Niswonger (1934) and Thompson (1946). The closest speaking space is not the free way
space. These two measurements, by two different methods based on different principles
should not be confused.
The free way space establishes vertical dimension when the muscles involved are
at complete rest, or in physiologic tonus and the mandible is in its rest portion. The closest
speaking space measures vertical dimension when the mandible and muscles involved are
in physiologic function of speech. In one method everything involved is still (static) an in
the other method everything is moving (dynamic or functional).

8)

FACIAL EXPRESSION -

An experienced dentist has the advantage of recognizing the released facial


expression when patients jaws are at rest.
In normally related jaws, the lips will be even antero posteriorly and in slight
contact.
In a protruded mandible, lips are not evenly related antero posteriorly, lower lip will
be anterior to the upper lip and not in contact.
In a retruded mandible, lips will not be even. Lower lip will be distal to the upper
and not in contact.
The skin around the eyes and over the chin will be relaxed. Relaxation around the
nares reflects unobstructed breathing.

All these evidences of rest position of the maxillomai1dibular musculature are the
indications for recording a measurement of the vertical dimension of rest.
9) OPEN REST METHOD Douglas and Maritato conducted a study in 1965 and described the open rest
position' of establishing the vertical dimension of occlusion. Open rest position is an
unstrained mouth breathing position. The lips are slightly parted to permit observation as
the mesial marginal ridges of the upper and lower bicuspids. Their positions, which
represent the upper and lower occlusal planes are related to the corners of the mouth.
Pre-extraction cephalometric radiographs of 20 patients made with the mandible in
the open rest position indicated that the upper occlusal rim should be 3 mm above the
comer of the mouth in the premolar region and that the occlusal plane of the lower rim
should be 2 mm below the corner of the mouth.
The authors concluded that:
a. Open rest position of the mandible is a practical and relatively constant
means for relating the upper and lower occlusal planes in the first bicuspid
regions to the comers of the mouth.
b. The open rest position is unstrained and only slightly opened from
the physiological rest position of the mandible.
c. The development of the upper occlusal plane approx. 3 mm above the
commisures of the lips and the lower occlusal plane approx. 2 mm below
the commisures of the lips will provide an adequate vertical dimension of
occlusion into a high percentage of patients.
d. The open rest technique is a relatively accurate method to determine the
vertical dimension of occlusion.

EVALVATION OF VERTICAL DIMENSIONS


1. Patients Tactile SensePlace the trial denture and that has good stability. Ask the patient to open and
close until the teeth contact. Ask the patient if the teeth appear to touch too soon, if
the jaws seem to close too far before they touch, or if the teeth feel first right.
This method is not too effective with senile patients or with those who have
impaired neuromuscular co-ordination.
2. Swallowing following by Relaxation With the dentures in place, instruct the patient to wipe his lips with the tip of
the tongue, swallow and let the shoulders drop in a relaxed position. Watch the
reference points and ask the patient to close the teeth together. Measurements can be
made between the points. Also if the patient is asked to swallow Several times, there

is light contact of the rims or teeth in the beginning of the swallowing cycle.
2. Use of words like - thirty three, fifty five and sixty six is helpful.
"Thirty three" - tip of the tongue should come just between the upper and lower rim /
teeth.
"Fifty five" - upper central Incisors edges should contact the lip at the junction of the
moist and dry mucosa.
"Sixty six" - Upper and Lower teeth should almost touch. "Emma",
"Mississippi" - teeth should not contact.

Tests of Vertical Jaw Relation of occlusion with occlusal/Rims


Following are some tests that aid the dentist in conforming the correct vertical relation of
occlusion with occlusal rims:
1. Judgment of overall facial support.
2. Visual observation of amount of space between the rims when the jaws are at rest.
3. Measurements between the dots on the face when jaws are at rest and when the
occlusal rims are in contact.
4. Observations made when sibilant containing words arc pronounced, to ensure that
the occlusal rims come close together but do not contact.
5. The final determination cannot be made by any method until the teeth are set in
position in the wax trial denture and the vertical dimension is verified in the
mouth.

CONCLUSION
None of the methods just listed, used alone, will yield an appropriate
vertical dimension of occlusion reliably in all patients. It is appropriate
therefore to use one or more of the methods to approximate the relationship
and then to use other methods to independently test the appropriateness of the
relationship initially estimated, before the record is sent for the set-up of
teeth.
When multiple independent methods used for determining the vertical
dimension appear to yield similar results, this (still preliminary) estimate can
be taken as the vertical height at which teeth should be set. When the
horizontal jaw relations have been established, the centric relation record will
be taken at this vertical dimension for transfer to the articulator.
Of course a further review of this tentative determination will occur later at
the try-in appointment, when teeth are set in the wax trial dentures and the
vertical dimension is verified in the mouth. At that time these methods will be
used again collectively to confirm the vertical dimension before completion
of the dentures.